AIMS AND OBJECTIVE: The aim of this study was to assess systematically the characteristics of patients and risk factors associated with nosocomial infections among ESRD patients undergoing hemodialysis.
METHODS: A systematic literature search was performed to identify eligible studies published during the period from inception to December 2018 pertaining to risk factors associated with nosocomial infections among hemodialysis patients. The relevant studies were generated through a computerized search on five databases (PubMed, EBSCOhost, Google Scholar, ScienceDirect and Scopus) using the Mesh Words: nosocomial infections, hospital acquired infections, healthcare associated infections, end stage renal disease, end stage renal failure, hemodialysis, and risk factors. The complete protocol has been registered under PROSPERO (CRD42019124099).
RESULTS: Initially, 1411 articles were retrieved. Out of these, 24 were duplicates and hence were removed. Out of 1387 remaining articles, 1337 were removed based on irrelevant titles and/or abstracts. Subsequently, the full texts of 50 articles were reviewed and 41 studies were excluded at this stage due to lack of relevant information. Finally, nine articles were selected for this review. Longer hospital stay, longer duration on hemodialysis, multiple catheter sites, longer catheterization, age group, lower white blood cell count, history of blood transfusion, and diabetes were identified as the major risk factors for nosocomial infections among hemodialysis patients.
CONCLUSION: The results of this review indicate an information gap and potential benefits of additional preventive measures to further reduce the risk of infections in hemodialysis population. Moreover, several patient-related and facility-related risk factors were consistently observed in the studies included in this review, which require optimal control measures.
METHOD: An exploratory phenomenology qualitative study was conducted whereby subjects were purposively selected based on previous experience in observing Ramadan fasting. Face-to-face in-depth interviews were conducted, and study data were analyzed thematically and iteratively coded using a constant comparison method.
RESULTS: Four major themes emerged from the data, namely: (i) "fasting experiences", (ii) "perceived side effects of fasting", (iii) "health-seeking behavior" and, (iv) "education and awareness needs". Patients expressed the significance of Ramadan fasting as well as the perceived impact of fasting on their health. Additionally, there is lack of health-seeking behaviour observed among patients thus, raising needs for awareness and education related to Ramadan fasting.
CONCLUSIONS: Findings of this study shed light on patients' experiences and perceptions regarding Ramadan fasting which warrants the needs for an effective communication between patients and health care practitioners through a structured-Ramadan specific education program.
METHOD AND ANALYSIS: A single center, prospective, randomized, parallel design, single-blind trial will be conducted in the Malaysian state of Kelantan among postdialysis euvolemic hypertensive patients that are on regular dialysis at least 3 times a week. The primary outcome of the trial will be to note the effectiveness of losartan (RAAS inhibitor) in reducing systolic BP 140 mm Hg will be randomized using Covariate Adaptive Randomization to standard or treatment arm. Participants in the treatment arm will be given 50 mg of losartan once daily except on dialysis days, whereas the standard arm patients will be prescribed non-RAAS antihypertensive agents. The study participants will be followed for a period of 12 months. A Wilcoxon statistical test will be performed to note the difference in BP from baseline up to 12 months using Statistical Package for the Social Sciences (SPSS) 20.
ETHICAL AND TRIAL REGISTRATION: The study protocols are approved from the Ethical and Research Committee of the Universiti Sains Malaysia (USM/JEPeM/15050173). The trial is registered under the Australia New Zealand Clinical Trial Registry (ACTRN12615001322527). The trial was registered on 2/12/2015 and the 1st patient was enrolled on 10/12/2015. The trial was formally initiated on 16/02/2016.
CONCLUSION: Management of HTN among HD patients requires understanding the primary cause of HTN and treating accordingly. The current trial is an attempt to reduce BP among postdialysis euvolemic but hypertensive patients.
METHODOLOGY: A single center, prospective, single-blind randomized trial was conducted to estimate the survival of post-dialysis euvolemic hypertensive patients when treated with lorsartan 50 mg every other day. Post-dialysis euvolemic assessment was done by a body composition monitor. Covariate Adaptive Randomization was used for allocation of participants to the standard or intervention arm, and the follow-up duration was twelve months. The primary end point was achieving targeted blood pressure (BP) of <140/90 mm Hg and maintaining for 4 weeks, whereas secondary end point was all cause of mortality. Pre-, intra-, and post-dialysis session BP measurements were recorded, and survival trends were analyzed using Kaplan-Meier analysis.
RESULTS: Of the total 229 patients, 96 (41.9%) were identified as post-dialysis euvolemic hypertensive. Final samples of 88 (40.1%) patients were randomized into standard (n = 44) and intervention arms (n = 44), and 36 (81.8%) patients in each arm completed a follow-up of 12 months. A total of eight patients passed away during the 12-month follow-up period (6 deaths among standard arm and 2 in intervention arm). However, the probability of survival between both arms was not significant (p = 0.13). Cox regression analysis revealed that chances of survival were higher among the patients in the intervention (OR 3.17) arm than the standard arm (OR 0.31); however, the survival was found not statistically significant.
CONCLUSION: There was no statistical significant difference in 1 year survival of post-dialysis euvolemic hypertensive patients when treated with losartan 50 mg.
Aims and Objective: To identify an ideal systolic blood pressure range based on optimal survival among ESRD patients on dialysis.
Method: A systematic search for clinical trials assessing the impact of different systolic blood pressure range on mortality among ESRD patients on hemodialysis was conducted through PubMed, EBSCOhost, Science Direct, Google Scholar, and Scopus. All randomized control trials (RCTs) involving ESRD patients on hemodialysis with primary or secondary outcome of assessing the impact different systolic blood pressure range (140 mm Hg) on all-cause mortality were included. The quality of reporting of the included studies was evaluated using the Jadad scale. Two researchers independently conducted eligibility assessment. Discrepancies were resolved by discussion and consultation with a third researcher when needed. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated.
Results: A total of 1,787 research articles were identified during the initial search, after which six RCTs met our inclusion criteria. According to the Jadad scale, all six RCTs scored 3 points each for quality of reporting. Four RCTs employed pharmacological intervention while two RCTs assessed non-pharmacological intervention. Of the six RCTs, two studies were able to achieve a systolic blood pressure of <140 mm Hg at the end of trial with a RR for reduction in mortality of 0.56 (95% CI, 0.3-1.07; P = 0.08). Four RCTs were able to achieve a systolic blood pressure of >140 mm Hg at the end of trial, with the RR for reduction of mortality of 0.72 (95% CI, 0.54-0.96; P = 0.003). Overall, pooled estimates of the six RCTs suggested the reduction in systolic blood pressure statistically reduce all cause of mortality (RR, 0.69%; 95% CI, 0.53-0.90; P = 0.006) among ESRD patients on hemodialysis.
Conclusion: Though not statically significant, the current study identifies <140 mm Hg as a promising blood pressure range for optimum survival among ESRD patients on hemodialysis. However, further studies are required to establish an ideal blood pressure range among hemodialysis patients.
Systematic Review Registration: The study protocol was registered under PROSPERO (CRD42019121102).